Scenario A

Disaster has struck - hard on the heels of the COVID-19 pandemic, another disease outbreak has hit your fair city, Inverkeld. Residents are outraged and worried. There have already been 12 deaths.

The cause of the outbreak appears to be Legionella pneumophila. (Please refer to the Legionnaire’s Disease Fact Sheet for more information about the pathogen.)

Each member of your group will play one of the following roles as you attempt to tackle the disease outbreak and save your city:

  1. Provost (head of the city council)
  2. Representative from a national public health org. (Public Health Scotland)
  3. Epidemiologist (on secondment from Public Health Scotland)
  4. Director of the city’s main hospital (Queen Rose)
  5. City planner/civil servant
  6. Microbiologist (working in one of the NHS Scotland clinical labs)
  7. Public communications expert (past and current sci comm campaigns)
  8. Doctor at a major surgery in Inverkeld

You must work together, using the information that has been provided for you in the attached information packets, and decide what action(s) should be taken to control the Legionella outbreak currently plaguing your city, Inverkeld. Your actions should be evidence-based – use the peer-reviewed literature to decide on measures that will stop the pandemic in your scenario.

Your action points may include directives to gather more information (e.g., contact tracing of current cases, microbiological testing of food/water, etc.), or specific directives (e.g. public health measures, non-pharmaceutical interventions, etc.). Use the data/expertise of all group members. Be clear, concise, and specific.

You should submit 3-5 specific actions to control the pandemic, using the workshop 3 pro forma (available on MyPlace). Submit this by noon, Friday March 10th, via the submission link on MyPlace.

Information Packet A1

You are the provost of Inverkeld, elected in 2013.

The current population of Inverkeld (as of December 2022) is 150691. The demographic data for the city is shown below.

Inverkeld demographics (Source: Office for National Statistics)Inverkeld demographics (Source: Office for National Statistics)

Figure 1: Inverkeld demographics (Source: Office for National Statistics)

You were elected as a member of the popular “Environment First” party and made a number of election promises regarding a “Green New Deal” for Inverkeld. This is your first full year in office.

Voting intention by Inverkeld residents (Source: YouGov polling)

Figure 2: Voting intention by Inverkeld residents (Source: YouGov polling)

There are currently 43 elected councillors, representing the 5 main political parties in Inverkeld as follows:

Political Party Number of Seats
Revolutionary 3
Social Capital 12
Environment First 20
Wind Power 6
Social Redistribution 2



The overall budget (expenditures) for the 2021-2022 financial year is £581761876. A summary of expeditures by category for this financial year is shown below.

Public expenditures by category for the 2021-2022 financial year (Source: Inverkeld City Council)

Figure 3: Public expenditures by category for the 2021-2022 financial year (Source: Inverkeld City Council)

Your office has recently received a great deal of correspondence regarding the pandemic in Inverkeld. A representative sample of these e-mails is shown below.

From:
To:
Cc: Subject: This Disgraceful Pandemic

Dear Provost,

I am so angry to hear about this new pandemic in Inverkeld. This seems to be too much to bear on top of COVID, the cost of living crisis, and the war in Ukraine. It is just one tragedy after another.

I expect that your office is going to do something about all of the poor people dying as soon as possible.

Yours sincerely,
Wilson

From:
To:
Cc:
Subject: Pandemic Disaster for Businesses

Dear Provost,

This new pandemic in Inverkeld has the potential to destroy our businesses. I run a small coffee shop on the high street and practically had to close because of all the draconian lockdowns due to COVID.

I hope you realise how costly the last pandemic was for millions of people across the country, and that we can’t afford another one.

I sincerely hope that your office is going to do something about horrible pandemic very soon, keeping in mind the economic interests of businesses in our city and the fact that we cannot afford the draconian lockdowns you imposed during COVID.

All the best,
Su (Bella’s, proprietor)

From:
To:
Cc:
Subject: Government Overreach

Dear Provost,

I hate the idea that you and your office are going to use this new pandemic as yet another excuse for government overreach into citizens’ lives. I am sick and tired of government interference with my life, I have the right to go about my life without some do-gooder from a public health agency telling me that I need to wear a mask and can’t visit my grandmother.

Please do not use this disaster as another opportunity for oppressive lockdowns and government control of our lives.

All the best,
Rodrigo (a concerned voter)

From:
To:
Cc:
Subject:

Dear Provost,

I have just learned that my my nana’s best friend has passed away due to the new pandemic in Inverkeld. This is truly a tragedy.

This is especially terrible coming hard on the heels of all of our losses due to COVID-19.

I hope that, considering how many other families have also lost loved ones, that you and your office will be doing everything in their power to halt this pandemic and prevent more needless deaths.

Sincerely,
Roman

Information Packet A2

You are a representative from Public Health Scotland, sent to Inverkeld to help with the Legionella outbreak.

Your briefing packet includes the following documents:

Guideline on the management of Legionella cases, incidents,outbreaks and clusters in the community: Health Protection Network Scottish Guidance

Cluster of Legionella longbeachae cases in Scotland in September/October 2013: Report from a national Incident Management Team

Kawasaki, Takeshi et al. “Diagnostic accuracy of urinary antigen tests for legionellosis: A systematic review and meta-analysis.” Respiratory investigation vol. 60,2 (2022): 205-214.

Nisar, Muhammad Atif et al. “Legionella pneumophila and Protozoan Hosts: Implications for the Control of Hospital and Potable Water Systems.” Pathogens (Basel, Switzerland) vol. 9,4 286. 15 Apr. 2020,

Information Packet A3

You are an epidemiologist working for Public Health Scotland, sent to Inverkeld to help with the Legionella outbreak.

A team of scientists working together have cultured Legionella pneumophila from a number of patient sputum samples; isolated genomic DNA from these strains; sequenced this genomic DNA using an Illumina MiSeq platform; assembled the short paired-end reads; and compared these assemblies to the extant Legionella pneumophila sequences available in the NCBI databases. The results of these experiments are summarised in the table below.

Patient NCBI accession of closest database match
1 GCA_022577225.1
2 GCA_022577275.1
3 GCA_022577345.1
4 GCA_022576795.1
5 GCA_022577275.1
6 GCA_022577225.1
7 GCA_022577345.1
8 GCA_022577345.1
9 GCA_022577225.1
10 GCA_022577345.1



Your briefing packet also includes the following documents:

Gorzynski, Jamie et al. “Epidemiological analysis of Legionnaires’ disease in Scotland: a genomic study.” The Lancet. Microbe vol. 3,11 (2022): e835-e845.

Cameron, R L et al. “Comparison of Legionella longbeachae and Legionella pneumophila cases in Scotland; implications for diagnosis, treatment and public health response.” Journal of medical microbiology vol. 65,2 (2016): 142-146.

Information Packet A4

You are the director of Inverkeld’s main hospital, the Queen Rose, which has 500 beds across 8 different wards and 10 operating theatres. The annual operating budget for financial year 2021-2022 was £1.3 million, and average expenditures are shown by category in the figure below.

Hospital expenditures by category for financial year 2021-2022 (Source: NHS Scotland)

Figure 4: Hospital expenditures by category for financial year 2021-2022 (Source: NHS Scotland)

The Queen Rose has units specialising in coronary care; maternity care; paediatic care; an ear, nose, and throat clinic; an eye clinic; and an orthopedic unit.

There are currently 25 ICU beds (with ventilators) available, an increase from the 17 ICU beds in the Queen Rose in September 2019. Average ICU bed occupancy before and during the COVID-19 pandemic is in Figure x.

ICU bed occupancy for the Inverkeld Queen Rose hospital (Source: NHS Scotland)

Figure 5: ICU bed occupancy for the Inverkeld Queen Rose hospital (Source: NHS Scotland)

There are approximately 1.1m admissions to the Queen Rose hospital annually, the majority of these being to the emergency (A&E) department.

Admissions to the Inverkeld Queen Rose hospital by category (Source: NHS Scotland)

Figure 6: Admissions to the Inverkeld Queen Rose hospital by category (Source: NHS Scotland)

A&E waiting times have been called “unacceptably high” in recent months, both by the press and by tthe hospital ombudsman.

ICU waiting times for the Inverkeld Queen Rose hospital (Source: NHS Scotland)

Figure 7: ICU waiting times for the Inverkeld Queen Rose hospital (Source: NHS Scotland)

The Queen Rose has been set a goal of 25% reduction in sepsis mortality (compared to past years)and 50% reduction in the nosocomial transmission of superbugs such as methicillin-resistant Staphylococcus aureus (MRSA), Clostridiodes difficile (C. diff), and Candida auris (C. auris).

Key Performance Indicators (KPIs) related to infectious diseases for the Inverkeld Queen Rose hospital (Source: NHS Scotland)

Figure 8: Key Performance Indicators (KPIs) related to infectious diseases for the Inverkeld Queen Rose hospital (Source: NHS Scotland)

There are currently 75 patients in the Queen Rose with confirmed or suspected Legionnaire’s disease, with 17 of these patients currently in the ICU.

Information Packet A5

You are a civil servant working in Inverkeld, working closely with the provost, city council and various agencies including the NHS and and SEPA (Scottish Environment Protection Agency).

Some of the key Inverkeld facts and figures at a glance are summarized in the table below.

Community Amenities Details
Schools 3 primary schools, 1 secondary school, 1 college
Care Homes 2, each with ~50 bed capacity
Restaurants and Cafes 72
Parks and Playgrounds 4
Economic Indicators Details
GDP/capita £49145
Unemployment Rate 7%
Traffic and Transport Details
Traffic fatalities (average/month) 6



Most of the Inverkeld water supply comes from nearby Loch Cairnavar. There are two wastewater treatment plants serving Inverkeld, employing a total of 110 people.

Inverkeld water usage for 2021-2022 (Source: SEPA)

Figure 9: Inverkeld water usage for 2021-2022 (Source: SEPA)

Your briefing packet on Legionnaires’ Disease includes the following information.

Legionnaires’ Disease: Use water management programs in buildings to help prevent outbreaks CDC fact-sheet.

Currie, S L et al. “Legionella spp. in UK composts–a potential public health issue?.” Clinical microbiology and infection : the official publication of the European Society of Clinical Microbiology and Infectious Diseases vol. 20,4 (2014): O224-9.

McCormick, D et al. “Public health response to an outbreak of Legionnaires’ disease in Edinburgh, United Kingdom, June 2012.” Euro surveillance : bulletin Europeen sur les maladies transmissibles = European communicable disease bulletin vol. 17,28 20216. 12 Jul. 2012, doi:10.2807/ese.17.28.20216-en

Hyland, J M et al. “Outbreak of Legionnaires’ disease in West Fife: review of environmental guidelines needed.” Public health vol. 122,1 (2008): 79-83.

Information Packet A6

You are a microbiologist working in the bacteriology department at the Greater Inverkeld Clinical Laboratory. Your laboratory is equipped to handle a range of culture samples (including anaerobic and microaerobic organisms), and you routinely process1722 samples monthly.

You are familiar with the culture requirements for growth of Legionella pneumophila, and the UK SMI for Legionella identification (see documents below).

Legionella grown on BCYE agar. Image credit: [CDC](https://www.cdc.gov/legionella/resources/materials.html)

Figure 10: Legionella grown on BCYE agar. Image credit: CDC

UK SMI: Identification of Legionella species

Benitez, Alvaro J, and Jonas M Winchell. “Clinical application of a multiplex real-time PCR assay for simultaneous detection of Legionella species, Legionella pneumophila, and Legionella pneumophila serogroup 1.” Journal of clinical microbiology vol. 51,1 (2013): 348-51.

CDC guidance on processing environmental samples

Information Packet A7

You are a public communications expert, often employed by the Inverkeld city council to manage the PR response to different initiatives or crises. You have assembled the following information/resources for this meeting:

CDC Legionella Communications Resources

Legionnaires’ disease outbreak investigation toolbox: Developing Communications

Legionella awareness campaign highlights deadly legionella hotspots

Information Packet A8

You are one of the doctors at the largest surgery in Inverkeld. In the past fortnight, 32 of your patients have recently presented to the surgery with symptoms consistent with Legionnaire’s disease. You have therefore recently been familiarising yourself with the relevant literature:

Clinician Factsheet: Legionnaire’s Disease

Clinical features of Legionnaire’s Disease and Pontiac Fever

Diagnosis, Treatment, and Prevention - CDC guidelines

National Enhanced Legionella Surveillance Scotland

Mandell, Lionel A et al. “Infectious Diseases Society of America/American Thoracic Society consensus guidelines on the management of community-acquired pneumonia in adults.” Clinical infectious diseases : an official publication of the Infectious Diseases Society of America vol. 44 Suppl 2,Suppl 2 (2007): S27-72. doi:10.1086/511159

Kalil, Andre C et al. “Management of Adults With Hospital-acquired and Ventilator-associated Pneumonia: 2016 Clinical Practice Guidelines by the Infectious Diseases Society of America and the American Thoracic Society.” Clinical infectious diseases : an official publication of the Infectious Diseases Society of America vol. 63,5 (2016): e61-e111. doi:10.1093/cid/ciw353

Viasus, Diego et al. “Legionnaires’ Disease: Update on Diagnosis and Treatment.” Infectious diseases and therapy vol. 11,3 (2022): 973-986. doi:10.1007/s40121-022-00635-7